This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on October 13-14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, Inc - Houston was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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Observations
Based on a review of patient records and an interview with the project/facility director and clinical supervisor, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first two years, in five of ten patient records, as required.
The findings include:
Twenty four patient records were reviewed on October 13 & 14, 2011. Ten patient records were reviewed for the completion of an average of 2.5 psychotherapy hours per month. The facility failed to document an average of 2.5 hours of psychotherapy per month in patient records # 2, 3, 5, 7 and 14 .
Patient # 2 was admitted into treatment on May 27, 2011. The patient attended 1.75 hours of psychotherapy in July, 2 hours of psychotherapy in August and 2.5 hours of psychotherapy in September. Patient # 2 received an average of 2.08 hours of psychotherapy per month.
Patient # 3 was admitted into treatment on March 16, 2011. The patient attended .75 hours of psychotherapy in July, 1.25 hours of psychotherapy in August and 2.5 hours of psychotherapy in September. Patient # 3 received an average of 1.5 hours of psychotherapy per month.
Patient # 5 was admitted into treatment on July 8, 2011. The patient attended 1.75 hours of psychotherapy in August and 1.25 hours of psychotherapy in September. Patient # 5 received an average of 1.5 hours of psychotherapy per month.
Patient # 7 was admitted into treatment on May 6, 2011. The patient attended 2 hours of psychotherapy in July, 2.5 hours of psychotherapy in August and 2.5 hours of psychotherapy in September. Patient # 7 received an average of 2.33 hours of psychotherapy per month.
Patient # 14 was admitted into treatment on May 6, 2011. The patient attended 1.25 hours of psychotherapy in July, 2.5 hours of psychotherapy in August and 1.25 hours of psychotherapy in September. Patient # 2 received an average of 1.67 hours of psychotherapy per month.
The project/facility director and clinical supervisor were interviewed on October 14, 2011 and confirmed the aforementioned information.
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Plan of Correction
The director and clinical supervisor reviewed client charts with each counselor to identify those clients that may have not received the required amount of counseling during the last 6 months and determined issues associated to each client not receiving the required amount of counseling time. There were not many clients in this situation but for those that did not meet this counseling requirement we did identify we created individualized plans to correct this problem.
Clinical supervisor will monitor counselor's tracking sheets weekly to ensure if counseling time is not being met it can been identified and corrected quickly.
As a facility we do believe that the use of county transportation by some of clients has been a hindrance for some clients to get the required amount of counseling time each month.
The director has and is currently addressing issues with transportation services and Washington County to resolve this issue in a manner that will allow clients to use the needed transportation service to obtain treatment as well as to meet commitments relating to treatment that the facility.
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